Research Organizations

Extensive Research Description

My research interests span from collaborative translational science to clinical research and trials to population science and outcomes research using large databases. My research focus is dedicated to breast cancer, but has touched a number of key themes over the evolution of my career.

Chest wall recurrence after mastectomyMy early publications focused on the issue of chest wall recurrences after mastectomy – elucidating a simple clinical prediction model to predict prognosis that is used to this day, describing the role of post-mastectomy radiation therapy in reducing recurrence, and finding that reconstruction does not need to be taken down in order to effectively manage chest wall recurrences that occur in autologous flaps.

Sentinel node biopsy Beyond management of local recurrences, the understanding of how to optimally predict prognosis and manage regional disease became increasingly important, as it is known that lymph node status is the key determinant of outcome.I therefore did a number of studies evaluating sentinel node biopsy in breast cancer – identifying the most appropriate technique to use, characterizing the prognostic implications of micrometastases, and ultimately defining clinical prediction models for additional metastases in non-sentinel nodes in sentinel node positive patients.Many of these were seminal works from the largest study of patients who had sentinel node biopsy followed by axillary node dissection, and form the basis of our clinical practice today.

Screening:Costs and ValueAs the practice of sentinel node biopsy evolved, it became clear that minimal disease in the axilla did not have the same prognostic implications as more extensive disease.The once tightly held paradigm that we need to find any/all disease early and treat it therefore came under more scrutiny and my attention then turned to the critical evaluation of screening; national trends, the economic impact of this and ultimately, the value it brings in terms of improved outcomes.Some of this work has been used by national organizations, such as the US Preventative Services Task Force, in terms of guiding policy.I led several of these studies looking at data from the National Health Interview Survey, and collaborated on other studies evaluating data from SEER-Medicare with Yale’s Center for Outcomes Public Policy and Effectiveness Research (COPPER).

Margins In keeping with the overarching theme of optimal management of breast cancer and cost/value, our most recent work has been on looking at margins – how we evaluate these intraoperatively, and how we can reduce positive margin and re-excision rates.As a result, we recently completed the largest randomized controlled trial to date regarding the utility of cavity shave margins. We found that, with this technique, we could dramatically reduce the positive margin and re-excision rates for women undergoing partial mastectomy for breast cancer. This was the most rapidly accruing therapeutic clinical trial at Yale Cancer Center, and the data were published in the New England Journal of Medicine. I was the PI on this trial, and led many of the other studies we did on this topic.

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